R a n J. Bradley Randleman d l e m a n REFRACTIVE SURGERY RR AN INTERACTIVE CASE-BASED APPROACH ee ff rr aa cc Refractive Surgery: An Interactive Case-Based Approach presents all of the necessary refractive tt surgery material to make an informed decision regarding diagnosis and management plans. ii Rather than utilizing the standard organization of most books, where major points are fi rst vv ee introduced and then explained through a series of writings and references, this book relies on SS the clinical decision-making process involved with treating refractive surgery patients. uu rr Refractive Surgery: An Interactive Case-Based Approach by Dr. J. Bradley Randleman gg builds upon foundational initial chapters through the case presentations and focused case ee discussions, encompassing the major topics in refractive surgery today. For each case, the rr critical question is simply, “What data in this chart are the most critical to consider when yy :: evaluating this patient for surgery?” AA NN AN INTERACTIVE CASE-BASED APPROACH Refractive Surgery: An Interactive Case-Based Approach is unique in its format. Specifi cally, I I NN the book facilitates active learning by forcing the reader to think through a series of questions TT EE surrounding each patient scenario. This active learning not only facilitates better recall of the RR information presented but also mimics the actual physician-to-patient clinical experience, AA CC making this book more relevant than other routine refractive surgery books. TT II VV EE Bonus! C C AA This dynamic learning tool is also supplemented by interactive online video material to further SS EE the learning experience. Enhance the clinical decision-making process by watching the videos -- BB and then answering a series of questions that lead to the conclusion of each scenario. AA SS EE DD By challenging the reader to perform the thinking and decision making up-front, and then A A providing some guidance on the most salient concepts for each case scenario presented PP PP along with resources to gain a deeper understanding of the most complex concepts, RR Refractive Surgery: An Interactive Case-Based Approach engages the reader more in the OO AA learning process thereby allowing him or her to absorb and retain signifi cantly more CC HH information to apply to patient care and the education of others. Ophthalmologists, residents, fellows, and resident and fellowship educators who want to update their refractive surgery knowledge base will appreciate the unique format and style of Refractive Surgery: An Interactive Case-Based Approach. SLACK Incorporated MEDICAL/Ophthalmology 1122--00447799__RRaannddlleemmaann__RReeffrraaccttiivveeSSuurrggeerryyFFuullllCCoovveerr..iinndddd 11 11//99//22001144 11::3344::2244 PPMM J. Bradley Randleman, MD Editor-in-Chief, Journal of Refractive Surgery Professor, Emory University Department of Ophthalmology Director, Cornea, External Disease, and Refractive Surgery Section Emory Eye Center, Emory University Atlanta, Georgia www.Healio.com/books ISBN: 978-1-61711-036-8 Copyright © 2014 by SLACK Incorporated Dr. J. Bradley Randleman has no fi nancial or proprietary interest in the materials presented herein. Dr. Douglas D. Koch is a consultant for Alcon, AMO, Revision Optics, and Ziemer. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews. Th e procedures and practices described in this publication should be implemented in a manner consistent with the profes- sional standards set for the circumstances that apply in each specifi c situation. Every eff ort has been made to confi rm the accuracy of the information presented and to correctly relate generally accepted practices. Th e authors, editors, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein. Th ere is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dos- ages are in accordance with currently accepted/recommended practice. Off -label uses of drugs may be discussed. Due to continuing research, changes in government policy and regulations, and various eff ects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA. Each professional should determine the FDA status of any drug or device prior to use in their practice. Any review or mention of specifi c companies or products is not intended as an endorsement by the author or publisher. SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians pro- vide important feedback on the content that we publish. We welcome feedback on this work. Published by: SLACK Incorporated 6900 Grove Road Th orofare, NJ 08086 USA Telephone: 856-848-1000 Fax: 856-848-6091 www.slackbooks.com Contact SLACK Incorporated for more information about other books in this fi eld or about the availability of our books from distributors outside the United States. Library of Congress Cataloging-in-Publication Data Randleman, J. Bradley (James Bradley), 1970- author. Refractive surgery : an interactive case-based approach / J. Bradley Randleman. p. ; cm. Includes bibliographical references and index. ISBN 978-1-61711-036-8 (paperback) I. Title. [DNLM: 1. Refractive Surgical Procedures--methods--Case Reports. WW 340] RE925 617.7’55--dc23 2013044408 For permission to reprint material in another publication, contact SLACK Incorporated. Authorization to photocopy items for internal, personal, or academic use is granted by SLACK Incorporated provided that the appropriate fee is paid directly to Copyright Clearance Center. Prior to photocopying items, please contact the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923 USA; phone: 978-750-8400; website: www.copyright.com; email: [email protected] Please note that the purchase of this e-book comes with an associated Web site or DVD. If you are interested in receiving a copy, please contact us at [email protected] D EDICATION To my darling Claudia, who loves me, supports me, amazes me, and inspires me… To my three wonderful children, Taylor, Casey, and Mia, who enliven me and keep me young in mind and spirit… To my father, who demonstrated teaching through coaching, and who taught me to always do my best to teach what I know to others… …and to my mother, Patricia, whose boundless curiosity about life stimulated my scientific pursuits, and who loved a good puzzle—she would have definitely enjoyed reading this book! C ONTENTS Dedication ..................................................................................................................................................iii Acknowledgments ......................................................................................................................................vi About the Author ......................................................................................................................................vii Foreword by Douglas D. Koch, MD .........................................................................................................viii Introduction ...............................................................................................................................................ix Section I Refractive Surgery: An Interactive Case-Based Approach ...................1 Chapter 1 Fundamentals of Refractive Surgery ...........................................................................3 Chapter 2 Preoperative Patient Evaluation .................................................................................15 Chapter 3 Corneal Topography and Biomechanical Evaluation .............................................23 Chapter 4 Basic Techniques for Refractive Surgical Procedures ............................................39 Chapter 5 Overview of Refractive Surgical Complications .....................................................45 Chapter 6 Refractive Surgery: The Decision-Making Process ................................................69 Section II Case Studies in Refractive Surgery ......................................................77 Introduction ..................................................................................................................................................79 Part 1: Preoperative Evaluations ...............................................................................................................81 Case 1 .............................................................................................................................82 Case 2 .............................................................................................................................88 Case 3 .............................................................................................................................94 Case 4 ...........................................................................................................................100 Case 5 ...........................................................................................................................108 Case 6 ...........................................................................................................................114 Case 7 ...........................................................................................................................120 Case 8 ...........................................................................................................................126 Case 9 ...........................................................................................................................132 Case 10 .........................................................................................................................142 Case 11 .........................................................................................................................148 Case 12 .........................................................................................................................154 Case 13 .........................................................................................................................164 Case 14 .........................................................................................................................174 Case 15 .........................................................................................................................180 Case 16 .........................................................................................................................192 Case 17 .........................................................................................................................200 Case 18 .........................................................................................................................212 Part 2: Postoperative Evaluations ............................................................................................................223 Case 19 .........................................................................................................................224 Case 20 .........................................................................................................................230 Contents v Case 21 .........................................................................................................................236 Case 22 .........................................................................................................................240 Case 23 .........................................................................................................................246 Case 24 .........................................................................................................................252 Case 25 .........................................................................................................................258 Case 26 .........................................................................................................................262 Case 27 .........................................................................................................................268 Case 28 .........................................................................................................................274 Case 29 .........................................................................................................................280 Case 30 .........................................................................................................................284 Case 31 .........................................................................................................................290 Case 32 .........................................................................................................................296 Case 33 .........................................................................................................................302 Case 34 .........................................................................................................................316 Case 35 .........................................................................................................................324 Case 36 .........................................................................................................................332 Appendix: Case Index ............................................................................................................................339 A CKNOWLEDGMENTS This project grew out of my work over the years with cornea fellows and residents at Emory University, and I would like to thank all of them for their direct and indirect contributions to this process. The cases may never have made it to print if not for the diligent efforts by two wonderful women who assisted me in their compilation: Cassandra Battle and Rhonda Hardaway-Brown. Sonia Yoo, MD provided exceptional images to accompany the text in key sections, and I thank her for that help! Of special note, the following individuals were instrumental in bringing this text to its final form through their critical review: Jenifer G. Bromley, MD; Sumitra S. Khandelwal, MD; Claudia E. Perez-Straziota, MD; Rupa D. Shah, MD; and Maria A. Woodward, MD. A A BOUT THE UTHOR J. Bradley Randleman, MD, is a Professor in the Department of Ophthalmology at the Emory University School of Medicine and director of the Cornea, External Disease, and Refractive Surgery Section at the Emory Eye Center. A widely respected cornea specialist, his areas of expertise include corneal and intraocular refractive sur- gical procedures, the management of corneal and exter- nal eye diseases, corneal collagen cross-linking, corneal transplantation and cataract surgery. His primary research interests include preoperative refractive surgical screening, the avoidance, diagnosis, and management of refractive surgical complications; and diagnosis and management of corneal ectatic disorders. Dr. Randleman received his BA degree from Columbia College at Columbia University in New York City with a joint major in biology and psychology. He earned his MD degree from Texas Tech University School of Medicine in Lubbock, Texas, where he was elected to the Alpha Omega Alpha Medical Honor Society in his junior year. He then completed his ophthalmology residency training at Emory University, where he received the Outstanding Teaching Resident award while he served as Chief Resident in his final year. Dr. Randleman joined the Emory faculty and served as Assistant Residency Director for 2 years while also completing a fellowship in cornea/external disease, and refractive surgery at Emory University. In 2004, he was awarded the prestigious Claes Dohlman Society Award, which is given annually to only one individual in the United States for academic and surgical excellence in cornea and refractive surgery training. Since practicing and teaching at Emory, he has trained more than 80 physicians in cataract surgery, refractive surgery, and corneal transplantation. In 2007, Dr. Randleman was awarded the Secretariat Award from the American Academy of Ophthalmology (AAO) for special contributions to the field of ophthalmology. In 2010, he was presented the innagural Binkhorst Young Ophthalmologist Award from the American Society of Cataract and Refractive Surgery (ASCRS). In 2011, Dr. Randleman was awarded the Kritzinger Memorial Award from the International Society of Refractive Surgery (ISRS). He was elected to the “135 Leading Ophthalmologists in America” listing by Becker’s ASC Review (Ambulatory Surgery Centers). Dr. Randleman was also named as a “Top Ophthalmologist in America” by Castle Connolly Medical Ltd since 2010 and he is named as one of the “Best Doctors in America” by US News & World Reports. Dr. Randleman has served as Editor-in-Chief for the Journal of Refractive Surgery since 2010. He has authored more than 90 peer-reviewed publications in leading ophthalmology journals in addition to 15 book chapters on refractive surgery evaluation and management of complications, and he co-edited the book Corneal Collagen Cross-Linking with Farhad Hafezi, MD, PhD. F OREWORD Every year my fellows, residents, and students ask me to recommend the best book for learning about refractive surgery. Every year I tell them that, although there are many excellent books on this topic, there isn’t one go-to text. Until now. Refractive Surgery: An Interactive Case-Based Approach by J. Bradley Randleman is that book. It has just what learners, and more experienced surgeons as well, need to grasp the basics of refrac- tive surgery and to begin developing the clinical acumen required to care for refractive surgery patients. Why this book? • It is engaging. When I picked it up, I expected to read small sections at a time, but instead I read most of it at one sitting. Really? A “textbook” that one cannot put down? The case-based approach is ideal for involving the reader by stimulating inquiry and forcing one to think as a clinician. The cases are clinical puzzles that challenge (and entertain) us. • It is comprehensive. It addresses all of the key refractive surgery procedures and remarkable array of preoperative clinical presentations and postoperative complications. • It is beautifully illustrated. So much of what we decide in refractive surgery is based on evaluation of studies, and Dr. Randleman provides superb illustrations for each case and often supplements these with additional figures that enrich the discussion. • It is informative. Each case is discussed in detail with clearly delineated sections and informa- tive, pertinent references. • It is a reference text. The initial chapters provide an excellent introduction to refractive sur- gery, and the appendix enables the reader to look up cases and study selected topics as needs or interests might dictate. This book belongs in the hands of all aspiring refractive surgeons and those who simply want to know more about this field. I finally have “the” book that I will recommend to my trainees. Douglas D. Koch, MD Professor and Allen, Mosbacher, and Law Chair in Ophthalmology Cullen Eye Institute Baylor College of Medicine Houston, Texas I NTRODUCTION Refractive surgery has gone through extraordinary changes over the past 30 years; moving from a rogue surgical concept, with limited procedural options suitable for only the most pioneering patients and surgeons, to mainstream acceptance by surgeons and patients as a safe, effective, and reasonable choice for appropriate individuals. Although initial procedures focused primarily on altering the cornea to modify refraction for a narrow range of errors, surgeons now have a variety of corneal techniques, including corneal (incisional, laser ablative, implants) and intraocular (pha- kic lens implantation and refractive crystalline lens exchange) procedures. These procedures, to varying degrees, can address most refractive errors through the functional range of human vision. Although some of these techniques have reached relative maturity in their development, even our most venerable procedures to date—excimer laser corneal ablation and cataract surgery with intraocular lens implantation—are constantly undergoing revision of surgical indications, tech- niques, and the technology available to reach our goals. At the same time, refractive surgery is finally getting the academic attention it deserves! In the United States, medical residents are now required to become exposed to, and educated about, refractive surgery. For example, an entire volume of the Basic and Clinical Science Course from the American Academy of Othalmology is dedicated solely to the study of refractive surgery, and there are now Accreditation Council for Graduate Medical Education guidelines in place to ensure medical residents are exposed to refractive surgery didactics and surgery (www.acgme.org). This means that all eye care professionals, not just those who maintain a dedicated refractive surgical practice, must be aware of the conditions with which their patients may present before and after refractive surgery to most effectively counsel, diagnose, and treat their patient population. With the constant addition of new techniques and technologies comes the need for learning strategies to educate the novice surgeon, and keep even the seasoned veteran up to date, on the best practice patterns for the wide variety of patients who will present to our offices searching for improved vision independent from visual aids. However, most medical residents feel they receive insufficient exposure to refractive surgical concepts and few actually perform any refractive surgery during training. Furthermore, although many conclusions have been collectively reached in numerous areas of patient evaluation, surgical technique, and avoidance and management of surgical complications, countless areas of debate and controversy remain. The goal of this book is to present where consensus exists today and to present varying elements of discussion in areas where controversy remains. Developing the Interactive Case-Based Approach This book has evolved from the hands-on exercises my cornea fellows and residents have gone through with me over the years. Refractive surgery patient evaluations are particularly well suited for chart review, and my trainees have walked themselves through each chart, looking for salient information contained within the notes and images. We discuss the relevant and irrelevant data in each situation, which is similar to having the medical chart accessible when these same patients are evaluated by them or you. Some cases were easily navigated, while others proved puzzling over and over again. These puzzling cases made it into the “interesting case file” folder, which finally outgrew its confines and became this text. How to Use This Book Regular textbooks and peer-reviewed publications are an invaluable source of knowledge. However, knowledge acquisition through simple reading is a passive process; the information is presented and you, the reader, absorb it. In contrast, many studies have shown that most “learn- ers” learn best when the process is active and engaging, forcing them to think rather than merely